Injury, Int. J. Care Injured 44 (2013) 1953–1955

Case report

Simultaneous bilateral tibial tuberosity avulsion fractures inadolescence: Case report and review of 60 years of literature

Shuvendu P. Roy, Kushal Nag *

Department of Orthopaedics, Sir Ganga Ram Hospital, New Delhi, India

A R T I C L E I N F O

Article history:

Accepted 7 April 2013

Keywords:

Tibial tuberosity

Simultaneous bilateral avulsion

Literature review

A B S T R A C T

Simultaneous bilateral avulsion fracture of the tibial tuberosity is a rare injury. Since the first reported

case in the 1950s only 21 such cases have been reported in literature. When they do occur, it is usually in

an adolescent athletic male, generally in the absence of any underlying pathology although rarely it may

be associated with an underlying connective tissue disorder. The age range of the injury corresponds to

the time of growth plate closure and maturation of the fibro-cartillagenous attachment of the tuberosity.

Most of the fractures require open reduction and internal fixation and usually heal well without any

significant complications.

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Introduction

Avulsion fracture of the tibial tubercle is not a common injury.The incidence ranges from 0.4% to 2.7% of all epiphyseal injuries.1,2

Simultaneous bilateral avulsion fractures of the tibial tuberosityare extremely rare. Borsch-Madsen first described this injury in1955. Since 1955 only twenty-one such cases have been reportedin literature (Table 1). It occurs in a vulnerable period when thephysis is undergoing physiologic changes that weaken its ability toresist tensing loading. The age range corresponds to the time ofgrowth plate closure and maturation of the fibro-cartillagenousattachment of the tuberosity. Watson-Jones3 classified thesefractures into three types which was further modified by Ogdenet al.4 who subdivided the three types into A and B according tocomminution and by Ryu and Debenham5 who proposed theaddition of a type IV (propagation of the fracture line into theposterior cortex). We are reporting a simultaneous bilateral tibialtubercle avulsion fracture in a 14-year-old boy while playing fieldhockey. The purpose of this article is to review the literature overthe past 60 years to present an over view regarding this rarepathology.

Case report

A 14-year-old male boy was dribbling with the ball whileplaying field hockey. He was in the process of passing the ballforward with both his knees in the semi-flexed position when he

* Corresponding author. Tel.: +91 9911477748.

E-mail addresses: roy_sp27@yahoo.co.in (S.P. Roy), nag.kushal@gmail.com

(K. Nag).

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http://dx.doi.org/10.1016/j.injury.2013.04.006

felt sudden onset of pain in both his knees and fell down. He wasunable to weight bear and extend his knees. On examination therewas swelling and bruising around proximal tibia with palpabledeformity of the tibial tubercle. He denied any knee pain ordiscomfort prior to his injury. Radiographs showed bilateralavulsion fractures of the tibial tubercle; ‘Watson-Jones type II’ onthe right and ‘Watson-Jones type III’ on the left (Fig. 1). Heunderwent open reduction and internal fixation with partiallythreaded 4-mm cannulated screws and washer for each fracture(Fig. 2). He was placed in cylinder casts for 4 weeks after which hecommenced a course of intensive physiotherapy. He regainednormal function activity by 8 weeks and returned to sports by 12months. He had no problems with prominent metalwork or genurecurvatum. There was no disruption of the proximal tibialepiphyses at 18th month follow-up.

Discussion

This case adds to the small number of reported cases ofsimultaneous bilateral avulsion fractures of the tibial tuberosityover the past 60 years. The previous twenty-one reports have beenreviewed and summarised in Table 1. The average age was 14.04years and all except one patient were male. The male preponder-ance is also seen in unilateral fractures. It is thought to be due tothe greater number of boys participating in sport duringadolescence and the later age at which males undergo physiodesisof the tibial tubercle.6 In our case, the subject sustained his injurywhile playing field hockey. In the previous twenty-one cases,twenty six fractures occurred during jumping activities, ninefractures on the landing and seventeen fractures on the take-offphase of the jump. Five patients sustained their injuries duringrunning, one after a fall on both knees, one while playing soccer

Table 1List of cases reported in literature with brief details.

Author Year Age Sex Sport Mode of injury Osgood-Schlatter Watson-Jones

classification

Treatment Complications

R L

Borsch-Madsen 1955 17 M Tripping at stairs III III ORIF Removal of screw

due to skin erosion

Ogden et al. 1980 14 M Running Sudden stop Bilateral III III ORIF Post-op pulmonary

embolism at 4 weeks

Henard et al. 1983 M Fall on both knees ORIF

Maar et al. 1988 16 M Basketball Jump (take off) III III ORIF Removal of

prominent implant

at 3 years

Lepse et al. 1988 14 M Gymnastics Forward flip (landing) Bilateral III III ORIF

Inoue et al. 1991 16 M Jump (landing) Bilateral IV IV Casting Premature closure

of epiphyses bilaterally

Sibert et al. 1995 16 M Athletics Start of run II I ORIF

Mirly et al. 1996 14 M Running Start of run III III ORIF

Mosier et al. 2000 15 M Jump (take off) IV III ORIF

Ergun et al. 2003 16 M Basketball Jump (landing) II II ORIF Metal work

removed at 10

weeks

Tamborlane et al. 2004 9 M Running Sudden stop Bilateral No data

given

ORIF Subsequently

diagnosed with

osteogenesis

imperfecta

Hamilton et al. 2006 13 M Soccer Jumping (take off) I II ORIF

Slobogean et al. 2006 16 M Running Sudden stop III IV R: ORIF

L: closed

reduction

Flexion deformity

at 16 months

follow up on right

side

Georgiou et al. 2006 17 M Athletics Jump (take off) III III ORIF

Mckoy et al. 2006 15 M Running Sudden stop IV IV ORIF Compartment

syndrome of right

leg, recurrent

avulsion of left

tibial tubercle at

1 year

Neugbauer et al. 2007 16 M Gymnastics Jump (take off) III III ORIF

Arredondo-Gomez et al. 2007 14 M Soccer Indirect trauma III III ORIF

Kafer et al. 2008 13 M Long jump Take off and landing II III ORIF

Tulic et al. 2010 15 M Basketball Jump (take off) ORIF

Albuquerque et al. 2011 13 F Volleyball Jump (take off) III II ORIF

Gowda et al. 2012 16 M Jump (landing) Bilateral II II ORIF

Fig. 1. Radiographs showed bilateral avulsion fractures of the tibial tubercle, ‘Watson-Jones type II’ on the right and ‘Watson-Jones type III’ on the left.

S.P. Roy, K. Nag / Injury, Int. J. Care Injured 44 (2013) 1953–19551954

Fig. 2. Post-operative radiographs showing internal fixation with two partially

threaded 4-mm cannulated screws and washer for each fracture.

S.P. Roy, K. Nag / Injury, Int. J. Care Injured 44 (2013) 1953–1955 1955

and another one by tripping at the edge of the stairs (Table 1).Essentially, there are four main mechanisms responsible for thesefractures: (i) jumping up from a stationary position, i.e. take-off, (ii)landing on feet after a jump, (iii) block to extension, (iv) rapidforced knee flexion. The extent and severity of this type of fractureis related to the degree of knee flexion at the time of fracture andalso can correlate with ‘Watson-Jones’ classification. The tensileforce exerted by the quadriceps is transmitted to the tibial tuberclevia the patellar tendon. An imbalance in this tensile force isresponsible for the avulsion fracture. When the injury occurs withthe knee either in near-full extension or in flexion up to 308,avulsion of the tibial tubercle without fracture of the proximaltibial epiphysis is the usual result. With the knee in a position offlexion greater than 308 at the time of injury, it result is an avulsionof both the tibial tubercle and the proximal tibial epiphysis.7

The tibial tubercle develops at postnatal period primarily as astructural modification of the anterior portion of the proximaltibial epiphysis. The physis underlying the tuberosity is initiallycomprised almost entirely of fibrocartillage (resists tensile stress),rather than the columnar, hypertrophic cells (cannot resists tensilestress) of the growth zone. As the secondary centre of thetuberosity matures significant, concomitant histological changesoccur in the physis of the tuberosity. The fibrocartillage is graduallyreplaced by columnar, hypertrophic physeal cartilage in a proximalto distal direction. Thus a tissue plane that is normally resistant totension failure is replaced by another that is known to fail undertension. The final step in skeletal maturation is physiologicalepiphysiodesis. The physis of the proximal end of the tibia closesfirst, starting centrally and proceeding centrifugally. The regionunder the tuberosity closes last and closure proceeds from proximalto distal along the tuberosity. Thus the initial failure commences atdistal end of the tuberosity and propagates proximally.8 Osgood-Schlatter disease has been suggested as a predisposing factor fortibial avulsion fracture; however, this has not been proven.1

However, over motivated athletes with intensive training sufferingoccasional anterior knee pain should be taken into consideration forincreased risk. Out of the twenty-one patients with bilateral avulsionfractures, five had bilateral pre-injury symptoms suggestive ofOsgood-Schlatter disease. Out of the five one was eventuallydiagnosed with Osteogenesis Imperfecta.9

Associated collateral ligament injuries, anterior cruciate liga-ment tears and meniscal tears have been reported with avulsionfractures of the tibial tuberosity;1,10 however, no such injurieswere seen in our patient or the other reported patients of thebilateral injury. Reported complications from avulsion fractures ofthe tibial tuberosity are rare. Genu recurvatum has been postulatedbut never described. Loss of flexion, mal-union, non-union, patellainfera and compartment syndrome have all been seen.4,7,11 Onepatient with a bilateral injury had a postoperative pulmonary

embolism at 4th week. Two had problematic metalwork removedand one had their screws removed prophylactically. One of thepatients had a recurrent tibial tubercle fracture after one yearwhich healed satisfactorily (Table 1).

Extension of the fracture into the knee joint, leading to disruptionof the articular surface should ideally be treated by open reductionwith accurate anatomical restoration of congruity of the tibial jointsurface.12 The final choice of internal fixation devices should bemade according to fracture pattern to achieve a well-stabilizedfracture reduction and prevent re-displacement. If growth potentialin the proximal tibial remains, the position and the size of implantsare crucial. Surgery around the tibial tubercle in young patients withopen physis can be dangerous and catastrophic complications suchas angular deformity, leg length discrepancy, genu recurvatum orpremature epiphysiodesis have been previously reported in theliterature.4,13,14 In the published series to date, the overall outcomeof unilateral avulsion fractures treated by open reduction andinternal fixation is excellent. Most patients achieved bony union andfull restoration of function.4,7 Conservative management withclosed reduction and above-knee extension cast (for approximately4 weeks) is feasible in non-displaced or minimally-displaced fractures.Comparable satisfactory results are described in the 20 patients’ withbilateral fractures treated by internal fixation. Only one patient withbilateral type IV Watson-Jones avulsion fracture was treated withbilateral casting. However, at one year follow up the patient presentedwith premature closure of both tibial physis. Watson-Jones type III wasthe most common type of fracture seen in the bilateral injury group(50% of the fractures). Our patient had Watson-Jones types II and III.Due to the degree of displacement, open reduction and internalfixation was indicated. Our patient has a similar successful outcomewith no complications at 18 months follow up.

In conclusion, bilateral simultaneous avulsion fractures of thetibial tubercle are extremely rare. When they do occur, it is usuallyin an adolescent athletic male, generally in the absence of anyunderlying pathology although rarely it may be associated with anunderlying connective tissue disorder. A detailed history helps todefine the degree of trauma involved, and therefore, may obviatethe need for further unnecessary investigation. Most fracturesrequire open reduction and internal fixation and usually healwithout any significant complications.

References

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2. Bolesta MJ, Fitch RD. Tibial tubercle avulsions. J Pediatr Orthop 1986;6:186–92.3. Watson-Jones R. Fractures and joint injuries, 5th ed., vol. 2. Baltimore: Williams

& Wilkins; 1976. p. 1048–50.4. Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents.

J Bone Jt Surg [Am] 1980;62:205–15.5. Ryu RKN, Debenham JO. An unusual avulsion fracture of the proximal tibial

epiphysis. Clin Orthop 1985;194:181–4.6. McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fractures. Orthop Clin

North Am 2003;34:397–403.7. Borsch-Madsen P. On symmetrical bilateral fracture of the tuberositas tibiae

and eminentia intercondyloide. Acta Orthop Scand 1954/1955;24:44–9.8. Mankin HJ. The classic: lesions of the tibial tubercle occurring during adoles-

cence (by Osgood RB. Boston Med J 1903; 148: 114). Clin Orthop 1993;286:4–6.9. Tamborlane JW, Lin DY, Denton JR. Osteogenesis imperfecta presenting as

simultaneous bilateral tibial tubercle avulsion fractures in a child. A case report.J Pediatr Orthop 2004;24(6):620–2.

10. Lepse PS, McCarthy RE, McCullough FL. Simultaneous bilateral avulsion frac-tures of the tibial tuberosity. A case report. Clin Orthop 1988;229:232–5.

11. Pape JM, Goulet JA, Hensinger RN. Compartment syndrome complicating tibialtubercle avulsion. Clin Orthop 1993;295:201–4.

12. Georgiou G, Dimitrakopoulou A, Siapkara A, Kazakos K, Provelengios S. Simul-taneous bilateral tibialtubercle avulsion fracture in an adolescent: a case reportand review of the literature. Knee Surg Sports Traumatol Arthrosc 2007;15:147–9.

13. Christie MJ, Dvonch VM. Tibial tuberosity avulsion fracture in adolescents. JPediatr Orthop 1981;1:391–4.

14. Henard DC, Bobo RT. Avulsion fractures of the tibial tubercle in adolescents: areport of bilateral fractures and a review of the literature. Clin Orthop1983;177:182–7.